Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Woods Residential Health during CMS and state inspections, most recent first.
Failure to Assess Self-Administration of Medications: A resident with Type 2 DM, altered mental status, and muscle weakness had a medication cup with 4 tablets left at the bedside without an order or assessment for self-administration. The resident said the nurse usually watches them take meds, but this time the pills were left there while they were half asleep. An LPN admitted leaving the meds on the table, and the DON confirmed meds should not be left at the bedside without a self-administration order.
A hospice resident with CREST Syndrome Scleroderma and Rheumatoid Arthritis, who was cognitively intact, reported waking in severe morning pain and stated they wanted to be awakened for nighttime pain medication. Review of the care plan and orders showed scheduled morphine every four hours plus PRN dosing for breakthrough pain, but the MAR documented multiple missed midnight doses, with nursing staff recording that the medication was not given because the resident was sleeping. The UM and DON confirmed the doses were not administered despite orders and policies requiring pain management consistent with the resident’s care plan and expressed preferences.
A resident with Alzheimer’s dementia, admitted from a hospital and unable to complete a BIMs assessment, was identified by nursing staff as exit seeking during the first night but no specific elopement-prevention interventions were implemented. The resident repeatedly left their room overnight and required redirection, and the oncoming nurse verbally told CNAs to keep an eye on the resident. The next morning, while staff were passing breakfast trays and an LPN was doing a med pass near the smoker’s exit, the resident sat near the smoking area doors and then left the building by following a smoker through an unlocked, non-alarmed interior door routinely used for independent smoking. The resident walked off the premises and was later located at a nearby medical clinic and returned, with staff and internal review concluding that the resident had been assessed as an elopement risk but was not provided with appropriate interventions to prevent leaving the facility.
Several residents with severe cognitive impairment and total dependence on staff were repeatedly observed without accessible call lights, as devices were found on the floor, out of reach, or improperly placed. This occurred despite facility policy requiring call lights to be accessible and accommodations to be made for individual needs.
A resident with moderate cognitive impairment and multiple medical conditions repeatedly requested a room change due to dissatisfaction with their environment, lack of access to personal belongings, and frequent intrusions by other residents. Despite these requests and staff acknowledgment of an overstimulating environment, the facility did not address the resident's preferences or provide a room change policy, and no documented behaviors justified the resident's placement on a locked unit.
A resident with severe cognitive impairment and multiple comorbidities was discharged with unexplained bruising in various stages of healing, despite initial assessments showing no skin issues. Staff failed to thoroughly assess and document these injuries, and the facility could not determine the cause of most bruises. The required daily skin checks and reporting procedures were not followed, leading to a deficiency in protecting the resident from potential abuse or neglect.
A resident with a history of falls and requiring assistance with mobility was repeatedly observed without the prescribed fall mat next to the bed, as outlined in the care plan. Despite the care plan intervention, the fall mat was not in place during multiple observations, and staff could not account for its absence. Incident reports and the facility's fall policy were not provided during the survey.
A resident with cerebral infarction and bipolar disorder had a BIMS score indicating intact cognition, but the record also included a physician and psychologist capacity determination stating the resident was incapable of making medical decisions. Despite that finding, the resident signed advance directives, and the SSD said the resident was allowed to do so because she seemed coherent enough even though no new capacity determination had been completed.
A facility failed to maintain a homelike environment for two residents. One resident’s bed footboard was observed in disrepair with exposed wood and duct tape, and the condition remained unchanged on a later observation; the resident had Alzheimer’s disease and impaired cognition. Another resident’s floor tile was repeatedly observed to be chipped, stained, and in disrepair. The facility’s maintenance policy called for routine inspections to assure a safe, functional, sanitary, and comfortable environment.
Failure to complete annual PASARR review for a resident with Cerebral Infarction and Bipolar Disorder. The resident had an intact BIMS score and needed assistance with bed mobility and transfers, but the most recent PASARR on file was from the prior year. The SSD stated they would need to check whether an annual PASARR had been completed, and no updated PASARR or facility policy was provided by the end of the survey.
Failure to provide routine fingernail care for two residents. Two residents were observed with long nails and brown debris under the nails over multiple observations, and both stated their nails needed to be cut. An LPN acknowledged the nails were long and needed to be cut, but one resident's care was described as dependent ADL assistance and the other as supervision/setup help. The DON stated nail care was to be completed during ADL care, and the facility policy required routine cleaning and inspection of nails during ADL care on an ongoing basis.
A resident with impaired cognition and an active hematology follow-up order did not have the specialty appointment scheduled. The resident was observed in bed and reported hand pain, while the DON stated they were unaware of the hematology appointment.
A resident dependent on a ventilator had a circuit disconnect at the trach site while restless in bed, and staff did not respond immediately to the alarm. Another ventilator-dependent resident reported repeated long waits for call light response and described a circuit disconnection in two places, with the spouse stating the resident had quit breathing. Alarm logs showed low pressure, low minute volume, and disconnect alarms, while staff described a busy unit and differing views of how long the resident was disconnected.
Delayed Behavioral Health Services: A resident with schizophrenia and bipolar disorder, impaired cognition, and an order for monthly Haldol injections did not receive timely psych services. Surveyors requested psych notes and a behavioral services policy, but neither was provided by the end of survey. The SSD said the resident was on the list to be seen after a switch to a new NP, and the NHA stated psych evals were expected within the first week of admission pending consent.
Unsafe Bedside Medication Storage: A resident with ESRD on dialysis, CHF, DM, oxygen dependence, and polyosteoarthritis had a medication cup with multiple pills and two bottles of Nystatin Powder left on the bedside table, and the resident said the nurse leaves the meds for later self-administration. The EMR showed intact cognition, but there was no self-medication assessment; the DON stated meds should not be at the bedside and the nurse is expected to watch the resident consume medications.
Improper Storage of Nebulizer Mouthpieces: Two residents were observed with nebulizer mouthpieces left on their nightstands instead of stored in a bag when not in use. One resident had COPD, OSA, impaired cognition, and needed assistance with mobility, while the other had acute respiratory failure with hypoxia and severely impaired cognition. An LPN and the DON stated nebulizer mouthpieces should be stored in a bag, and the facility policy also required bag storage after cleaning and drying.
A resident's room was found with stained linens, a sticky floor, soiled baseboards, and feces on the toilet seat, despite facility procedures requiring daily cleaning and disinfection. The DON confirmed the room required cleaning, and the resident had severe cognitive impairment but was independent in mobility.
A resident's privacy was compromised due to improperly placed cameras in their room, which faced the entry door and allowed monitoring by the resident's mother. The cameras' positioning potentially infringed on the privacy of others in the hallway. The resident had severe cognitive impairment and was non-verbal, requiring full assistance from staff. Despite being informed of the privacy concerns, the resident's mother insisted on her right to place the cameras as she wished.
A resident with cognitive impairment and mobility issues was verbally and physically abused by an LPN, who yelled profanities and lifted a couch to force the resident off, causing them to fall. The incident was witnessed by staff and reported to the Assistant Director of Nursing. The facility's abuse policy was violated as residents are entitled to be free from all forms of abuse.
A resident was subjected to verbal and physical abuse by an LPN, who yelled profanities and lifted the couch the resident was lying on, causing them to fall. The incident, witnessed by a nurse and a CNA, was not reported to the SA until two days later, constituting a delay in reporting abuse allegations.
The facility failed to maintain proper sanitation and food safety standards, as observed with ineffective sanitizer buckets and improperly dried dishware in the kitchen. Additionally, resident refrigerators contained undated and expired food items, violating the facility's food safety policies.
The facility failed to provide adequate personal care for three residents, resulting in deficiencies in activities of daily living (ADLs). A resident with Parkinsonism did not receive scheduled showers, another with hemiplegia was not shaved during bed baths, and a third resident had excessively long toenails. Staff cited equipment shortages and scheduling issues, but the care plans and facility policies were not followed.
The facility failed to document and date PICC line dressings for two residents. One resident had a gauze dressing without a date or transparent cover, and the insertion site was not visible. The LPN and Unit Manager acknowledged the oversight. The second resident's transparent dressing was undated, and records lacked documentation of dressing changes. The DON confirmed the requirement for transparent, dated dressings and regular assessments.
A resident fell from a mechanical lift due to a ripped sling, with only one CNA present, contrary to policy requiring two staff. Additionally, a resident was observed using a vape pen in their room, violating the facility's smoking policy. These deficiencies highlight lapses in policy enforcement regarding mechanical lift use and smoking materials management.
The facility failed to securely store medications for four residents. One resident had a pill on their overbed table, another had a capsule on their window sill, a third had an inhaler on their table, and a fourth had a bag of pills they were not taking. The facility's policy requires medications to be taken with a nurse present and refused medications to be removed.
A resident with a recent above-knee amputation reported that their bed's height adjustment was non-functional, making a loud grinding noise. Despite informing multiple staff members, including maintenance and nursing staff, the issue was not addressed. Interviews revealed that staff were aware of the problem but did not report it. The Maintenance Director was unaware of the issue due to the absence of work orders, and the facility lacked a policy for reporting malfunctioning equipment.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to assess one resident for self-administration of medications out of two residents reviewed for self-administration. On 5/27/2026, an observation of the resident's room showed a medication cup containing 4 tablets sitting on a table extending over the resident's bed. The resident stated nursing staff usually watches them take medications before leaving the room, but this time the nurse left the pills there about an hour earlier, and the resident said they were half asleep and not totally sure what happened. The resident was admitted on 7/3/2024 with diagnoses of Type 2 diabetes, altered mental status, and muscle weakness, and the most recent MDS showed a BIMS score of 14, indicating intact cognition. Review of the resident's medication orders showed Hydralazine 25 mg, 2 tablets by mouth every 8 hours, and Acetaminophen 325 mg, 2 tablets by mouth every 6 hours. An LPN admitted leaving the medications sitting on the resident's table without making sure they were taken, stating medications should not be left at a resident's bedside and that if a resident is sleeping during medication administration, the medicine should be brought back to the medication cart. The DON confirmed medications should not be left at a resident's bedside if there is no order for self-administration. Review of the active orders and assessments did not reveal an order or assessment for self-administration of medications, and the facility policy stated a resident may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely.
Failure to Administer Scheduled Morphine for Hospice Resident’s Nighttime Pain
Penalty
Summary
Surveyors identified a failure to provide ordered pain management when nursing staff did not administer scheduled morphine doses to a hospice resident as prescribed. The resident, admitted with CREST Syndrome Scleroderma and Rheumatoid Arthritis and assessed as cognitively intact, reported waking up in severe pain in the mornings and believed they were not receiving their nighttime pain medication. The resident stated they wanted to be awakened for nighttime medication, even if asleep, so that their pain would not become severe. The resident’s care plan under hospice services included administering medications as ordered, observing for effectiveness, evaluating for signs and symptoms of pain, and providing care based on the resident’s end-of-life comfort preferences. Record review showed physician orders for morphine 100 mg/5 ml, 2 ml every four hours, and an additional PRN order for 2 ml every two hours for breakthrough pain. The MAR for March documented that seven scheduled midnight doses of morphine were not administered on multiple dates, with RN documentation indicating the medication was withheld because the resident was sleeping. The Unit Manager confirmed, based on the electronic record and narcotic sign-out sheets, that these doses were not given and stated the medication should have been administered unless the resident requested not to be awakened. The DON also stated that medications should be given as ordered. Facility policies on Pain Management and Hospice required that pain management be provided consistent with professional standards, the care plan, and resident goals and preferences, including directives for managing pain and uncomfortable symptoms.
Failure to Implement Elopement Interventions for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions to monitor and prevent elopement for a newly admitted resident with Alzheimer’s dementia who had been identified as an elopement risk. The resident was admitted from a hospital with diagnoses including Alzheimer’s and dementia, was unable to complete a BIMs assessment, and did not recognize their own name on nursing assessment. During the night shift, the resident repeatedly left their room, required redirection, and was described by the nurse as exit seeking. The nurse reported this exit-seeking behavior to the oncoming nurse and indicated the resident might need transfer to a secured unit, and the oncoming nurse was heard telling CNAs they needed to keep an eye on the resident. Despite this, no specific elopement-prevention intervention was put in place prior to the incident. On the morning of the elopement, the resident was observed on video sitting in a hallway chair and then moving to a dayroom sofa near the smoker’s exit doors while staff, including a nurse with a medication cart and CNAs passing breakfast trays, were present in the area. A CNA last saw the resident around the time breakfast trays were finished, then went to give another resident a 15–20 minute shower. Within approximately 45 minutes, the resident was no longer on the sofa and could not be located by staff. The CNA who had last seen the resident reported they had not received any direct report from night-shift CNAs about the resident’s exit-seeking behavior and initially thought the resident was a visitor when first observed sitting in the hallway. The resident exited the building through the smoker’s patio area, which was routinely unlocked during the day for independent smokers and, at the time of the incident, did not have an alarm on the interior set of doors. Staff interviews and a resident smoker confirmed that the interior door alarms were new and had not been in place or activated when smokers went out during the day prior to the elopement. Video review showed the resident walking down the sidewalk from the employee entrance toward the front of the building, and the facility later learned the resident had followed another resident who went out to smoke. The resident was found at a nearby medical clinic and returned to the facility, where they were noted to be confused by basic questions. The root cause identified by the facility was that the resident had scored as a risk for elopement on admission, but staff did not implement an intervention to prevent the resident from leaving the facility.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents who were reviewed for care needs. Multiple observations over several days showed that these residents, all of whom had severely impaired cognition and were totally dependent on staff for activities of daily living, did not have access to their call lights while in bed. Specifically, call lights were found on the floor, looped over the call box or vent cart, or hanging below the bed frame, making them inaccessible to the residents. The residents involved had significant medical conditions, including renal failure, diabetes, malnutrition, respiratory failure, and stroke. Facility policy required that call lights be accessible at each resident's bedside and that special accommodations be provided as needed, but these requirements were not met for the residents observed. The deficiency was identified through direct observation, interviews, and record review.
Failure to Honor Resident Room Change Preference and Support Self-Determination
Penalty
Summary
The facility failed to honor a resident's preference for a room change, as well as other expressed choices, for one resident with moderate cognitive impairment and diagnoses including diabetes, hypertension, and dementia. The resident reported dissatisfaction with their care, specifically noting lack of access to their clothes due to a locked closet, not being allowed to leave the locked unit or go outside for an extended period, and frequent intrusions by other residents into their room. The resident stated that requests for a room change were made to both the unit manager and their guardian, but these requests were not addressed. Staff interviews confirmed that the environment was overstimulating for the resident, affecting their participation in meals and activities, and that staff availability limited the resident's ability to leave the unit for activities such as visiting the vending machine. Observations included another resident entering the affected resident's room and using their belongings, which the resident indicated was a recurring issue. Review of the medical record showed no documented behaviors that would necessitate placement on a locked unit, and the director of nursing confirmed there was no specific criteria for such placement. The resident's care plan and progress notes did not document behaviors justifying the current room assignment. Additionally, a request for the facility's room change policy was made but no policy was provided by the end of the survey.
Failure to Assess and Document Unexplained Bruising
Penalty
Summary
A resident admitted for a 7-day respite stay, with diagnoses including Alzheimer's Disease, severe protein-calorie malnutrition, and diabetes, was found to have multiple bruises of various stages of healing on discharge. Initial nursing and nurse practitioner assessments documented no skin integrity issues or visible rashes upon admission. The resident, who was severely cognitively impaired and required significant assistance with activities of daily living, was later observed by a CNA to have redness on the right arm on the day of discharge, which was reported to a nurse, though the specific nurse was not recalled. Documentation submitted to the State Agency included photos of bruises on the resident's neck, left shoulder, hand, chest, and shin, with some bruises appearing to be more advanced in healing than others. The facility's internal investigation could not substantiate the causes of all the bruises except for the hand, and the DON acknowledged that staff should have noticed the bruising during care. The facility's wound care policy required CNAs to check residents' skin daily and report any new findings to the charge nurse or unit management for immediate intervention, but this process was not followed, resulting in the failure to thoroughly assess and document the resident's skin bruising and injury of unknown origin.
Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
The facility failed to implement a fall care plan intervention for one resident who had a history of falls and required assistance with bed mobility and transfers. The resident, who had diagnoses of cerebral infarction and bipolar disorder and demonstrated intact cognition, was observed multiple times without the prescribed fall mat on the left side of the bed, despite the care plan specifying this intervention. The resident reported using a cane for mobility and acknowledged having experienced falls in the facility. During the survey, incident and accident reports for the resident were requested but not provided. Repeated observations confirmed the absence of the fall mat, and the unit manager was unable to explain why the intervention was not in place, suggesting maintenance may have moved it. The facility's policy related to falls was also requested but not received by the end of the survey. The deficiency centers on the facility's failure to ensure that care plan interventions to prevent falls were consistently implemented as documented.
Advance Directive Completed Despite Prior Incompetency Determination
Penalty
Summary
The facility failed to ensure advance directives were completed properly for one resident. The resident was admitted with diagnoses of cerebral infarction and bipolar disorder, and the most recent MDS showed a BIMS score of 14/15, indicating intact cognition, with assistance needed for bed mobility and transfers. The medical record also included a capacity determination letter signed by a physician and a Licensed Psychologist stating the resident was incapable of making decisions regarding medical treatment, as well as an advance directive signed by the resident. During interview, the Social Service Director stated the resident's sisters were supposed to be pursuing guardianship but the facility did not know the status, and that the capacity determination had been completed to assess decision-making ability. The Social Service Director further stated the resident was allowed to sign the advance directives because she seemed coherent enough, although no new capacity determination had been completed.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to maintain a homelike environment for two residents. R151 was observed sitting in a wheelchair in the room while the footboard of the bed was in disrepair, with exposed wood and duct tape around it. The same condition was observed the following day. R151 was asked about the footboard and gave no explanation. The resident’s record showed admission with a diagnosis of Alzheimer’s disease, an MDS assessment noting impaired cognition, and a care plan addressing impaired cognitive functioning related to dementia, intellectually disabled status, decreased memory, decision making, difficulty with recall, and impaired thought processes. R184’s floor tile was observed on multiple days to be chipped, stained, and in disrepair. The facility policy titled Maintenance Inspection stated that the facility is to use a maintenance inspection program to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, and that the Director of Maintenance Services will perform routine inspections of the physical plant using the TELS program.
Failure to Complete Annual PASARR Review
Penalty
Summary
The facility failed to complete an annual pre-admission screening and resident review (PASARR) for one resident, R8, out of two residents reviewed for PASARR compliance. R8 was admitted to the facility on 5/5/2025 with diagnoses of Cerebral Infarction and Bipolar Disorder. The most recent Minimum Data Set assessment showed a Brief Interview for Mental Status score of 14/15, indicating intact cognition, and R8 required assistance with bed mobility and transfers. The most recent PASARR on record was dated 6/28/2024. During an interview on 8/13/2025 at 11:23 AM, the Social Service Director stated they would need to check whether an annual PASARR had been completed for R8. An updated PASARR was requested but not received by the end of the survey, and a facility policy related to PASARR completion was also requested but not received by the end of the survey.
Failure to Provide Routine Fingernail Care
Penalty
Summary
The facility failed to provide routine fingernail care for two residents who were unable to complete their own ADL care. R16 was observed in bed with long nails, a yellowish tint, and brown debris under the nails on 8/12/2025. When asked, R16 stated the nails were long and should be cut. The next day, R16 reported the nails had not been cut, and the nails were observed in the same condition. When the Unit Manager/LPN observed R16's nails, she stated they were long and needed to be cut, and explained that nail care was expected as needed and checked on shower days. R16's care plan identified an ADL self-care performance deficit related to absence of the right leg below the knee, history of joint replacement surgery, and muscle weakness, with personal hygiene listed as dependent with 1-person assist. R20 was observed with long nails and brown debris under the nails on 8/11/2025, and the nails remained in the same condition on 8/13/2025. R20 stated the nails needed to be cut. When the LPN observed R20's nails, she stated she would cut them if R20 let her and said staff had been directed to document refusals, though she was not sure if this was care planned. R20's care plan identified an ADL self-care performance deficit related to dementia, muscle weakness, osteochondritis dissecans, chronic kidney disease, old myocardial infarction, and hypertrophic disorder of the skin, with personal hygiene listed as supervision and setup help as needed. The DON stated nail care was to be completed during ADL care, and the facility policy stated routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis.
Failure to Schedule Hematology Follow-Up Appointment
Penalty
Summary
The facility failed to schedule a hematology follow-up appointment for one resident, who had an active order dated 3/18/2025 for hematology follow-up. The resident was admitted on 3/7/2025 with diagnoses of Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea, had a BIMS score of 12/15 indicating impaired cognition, and required assistance with bed mobility and transfers. During observation on 8/13/2025, the resident was in bed and stated they were doing okay but that their hands had been hurting them. When interviewed the same day, the DON reported they were unaware of the hematology appointment and would look into it. No further information was received by the end of the survey.
Delayed Response to Ventilator Alarms and Circuit Disconnections
Penalty
Summary
The facility failed to ensure timely monitoring and response for two residents who were dependent on mechanical ventilation and had tracheostomies. One resident was observed restless in bed with non-purposeful arm and leg movements while connected to the ventilator. During the observation, the circuit disconnected at the tracheostomy site when the resident moved an arm and tangled the tubing, an alarm sounded, and no staff were seen in the hallway. Staff did not arrive until about two minutes later, when they came from the nurse station area and reconnected the circuit. A second resident, who had diagnoses including acute and chronic respiratory failure, tracheostomy status, dependence on ventilator, and dependence on supplemental oxygen, reported that staff had taken 20 to 45 minutes to respond to call lights for toileting and getting back into bed. The resident and spouse described an event in which the ventilator circuit became disconnected in two places, including at the tracheostomy site and at an inline valve, while the resident was trying to use the call light for bathroom assistance. The resident reported struggling to breathe and possibly passing out, and the spouse stated the resident had quit breathing and was out of it when staff arrived. Record review and staff interviews showed ventilator alarms recorded low pressure, low minute volume, and disconnect alarms over several minutes during the event. The respiratory therapist and unit staff gave differing explanations about the alarm pattern and how long the resident may have been disconnected, while the assigned CNA and LPN reported the unit was busy and that staff were attending to other alarms and tasks. The resident’s care plan did not include interventions related to alarm response, and the facility’s ventilator information identified circuit disconnection and low minute ventilation as alarm conditions related to detached tubing or leaks in the circuit.
Delayed Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services in a timely manner for one resident with schizophrenia and bipolar disorder. The resident was admitted on 5/13/2025, had a most recent MDS assessment showing a BIMS score of 12/15 indicating impaired cognition, required assistance with bed mobility and transfers, and had an order for monthly Haldol injections. During survey, psychiatric notes for the resident were requested on 8/13/2025 at 11:04 AM and were not received by the end of survey. The Social Service Director stated at 11:23 AM that the resident was on the list to be seen and that the facility had just switched to a new Nurse Practitioner who comes in every Monday and would be seeing the resident soon. During a QAPI meeting at 12:30 PM, the NHA stated psychiatric evaluations were expected within the first week of admission pending consent, that the psychologist was present every other week and the psych PA weekly, and that psych evaluation could be delayed or not happen if consent was not provided. A facility policy related to behavioral services was requested and not received by the end of survey.
Unsafe Bedside Medication Storage
Penalty
Summary
The facility failed to ensure safe storage of medication for one resident who was reviewed for medication storage. On 8/11/25 at 9:49 AM, an observation found a medication cup containing approximately eight pills on the resident’s bedside table, including two blue oval pills, two large round white pills, one small round white pill, one small yellow round pill, one white capsule, and one yellowish clear gel capsule. Two bottles of Nystatin Powder were also observed on the bedside table on 8/11/25, 8/12/25, and 8/13/25. When questioned, the resident stated the nurse always leaves the pills for them to take when they are ready and identified some of the pills as blood pressure medication and the powder as being for under their folds. Record review showed the resident was admitted with End Stage Renal Disease with dependence on renal dialysis, chronic heart failure, diabetes, dependence on oxygen, and polyosteoarthritis. The EMR also showed intact cognition and that the resident used a walker and/or wheelchair and required partial/moderate assistance with basic activities of daily living. On 8/13/25, an LPN stated the resident liked to have medications given to them to take on their own time, while the DON stated medications should not be at the bedside and the nurse is expected to watch the resident consume medications. The resident did not have a Self-Medication Administration Assessment. Facility policy required observing resident consumption of medication and outlined criteria for self-administration and bedside storage, including safe storage arrangements and documentation in the care plan.
Improper Storage of Nebulizer Mouthpieces
Penalty
Summary
The facility failed to properly store nebulizer mouthpieces for two residents, R6 and R191, who were both observed with mouthpieces left out on their nightstands instead of being stored in a bag when not in use. On 8/13/2025, R6 was observed in bed wearing oxygen, with a nebulizer mouthpiece laying on the nightstand with no barrier beneath it and an undated line. R6 stated they used the nebulizer mouthpiece every day. Later that day, an LPN reported that nebulizer mouthpieces are stored in a bag and stated that R6 had just used the nebulizer before going outside, then said they were going to find a bag. R6 was admitted to the facility on 3/7/2025 with diagnoses of COPD and OSA, and the most recent MDS showed a BIMS score of 12/15, indicating impaired cognition; R6 also required assistance with bed mobility and transfers. R191 was observed on 8/11/2025 with a nebulizer machine and mouthpiece lying flat on top of the nightstand, not inside a plastic bag and not appearing to be drying, and the same condition was observed again on 8/13/2025. An LPN stated R191's nebulizer should be stored in a plastic bag when not in use. R191 was admitted with acute respiratory failure with hypoxia, had severely impaired cognition on the quarterly MDS, and the care plan addressed impaired pulmonary/respiratory status related to respiratory failure and tracheostomy. The Infection Control Nurse and the facility policy both stated nebulizer mouthpieces are to be stored in a bag when not in use.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that a resident's room was not maintained in a clean and homelike condition as required. During an unannounced visit, the resident was found unresponsive to attempts at arousal, and the room contained unidentifiable brown stains on both the fitted and flat sheets where the resident was lying. The floor was sticky, the door had dried liquid stains, and the baseboards were coated with an unknown caked-on substance. Additionally, the resident's bathroom had feces present on the toilet seat. These observations were confirmed during a follow-up visit with the Director of Nursing, who acknowledged the need for cleaning. A review of the facility's cleaning procedures indicated that resident rooms are to be cleaned daily, including disinfecting sinks and toilets, mopping floors, and spot washing walls and doors when soiled. The resident involved had a history of Schizoaffective Disorder, muscle weakness, hypertension, and severe cognitive impairment, but was independent with transfers and bed mobility. Despite these protocols and the resident's needs, the room was not maintained according to the facility's standards at the time of the survey.
Privacy Violation Due to Improper Camera Placement
Penalty
Summary
The facility failed to maintain privacy for a resident, identified as R704, due to the improper placement of electronic monitoring devices in the resident's room. Observations revealed that two cameras were positioned in a manner that allowed them to face the room's entry door, potentially infringing on the privacy of other residents and staff in the hallway. The cameras were connected to the resident's mother's phone, allowing her to monitor the room in real-time and hear conversations. The Assistant Nursing Home Administrator confirmed that the cameras were incorrectly positioned and should have been facing only the resident. R704 was a resident with a severely impaired cognitive condition, non-verbal, and dependent on staff for all mobility and activities of daily living. The Director of Nursing contacted R704's mother to address the camera placement issue, explaining that the current positioning could violate the privacy of others. However, R704's mother insisted on her right to place the cameras as she wished, leading to a conflict between respecting the resident's family's wishes and maintaining the privacy and dignity of other residents.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to prevent verbal and physical abuse of a resident, identified as R801, by a staff member. On the midnight shift of 10/13/2024, LPN C was observed by Nurse D and CNA E yelling profanities at R801, who was trying to sleep on a couch in the dayroom. When R801 refused to get up, LPN C continued to yell and then physically lifted the couch, causing R801 to roll onto the floor. This incident was reported to the Assistant Director of Nursing by the observing staff members. R801, who was admitted with diagnoses including the presence of a right artificial joint and depression, required staff assistance with bed mobility and transfers. The resident was unable to complete a mental status assessment, indicating significant cognitive impairment. A family member, who is also the guardian, was not informed that a staff member was involved in the fall. The facility's abuse policy clearly states that residents have the right to be free from all forms of abuse, which was violated in this incident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation in a timely manner involving a resident, identified as R801. The incident occurred during the midnight shift when an LPN was observed yelling profanities at R801 for trying to sleep on the couch in the dayroom. When the resident refused to get up, the LPN continued to yell and then physically lifted the couch, causing the resident to roll onto the floor. This incident was witnessed by a nurse and a CNA, who reported it to the Assistant Director of Nursing (ADON) the following morning. Despite the incident occurring on 10/12/2024, it was not reported to the State Agency (SA) until 10/14/2024. The delay in reporting was acknowledged by the ADON, who stated that the incident should have been reported immediately. The staff involved were subsequently educated on the proper procedures for reporting abuse allegations. The failure to report the incident promptly constituted a deficiency in the facility's compliance with regulations regarding the timely reporting of abuse allegations.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen and resident food storage areas. During an initial tour of the kitchen, it was observed that two red sanitizer buckets with wiping cloths did not contain an effective sanitizer solution, as confirmed by a test strip that failed to change color. Additionally, stacks of metal pans were found with visible water droplets, indicating they were not properly dried before stacking, which is against the 2017 FDA Food Code requirements for air drying utensils. Further inspection of the resident refrigerators revealed multiple undated food containers and expired food items, such as a bag of cut watermelon dated over a week prior and several black, mushy bananas. The facility's policy requires that foods brought in from outside be stored in sealable containers, labeled, and dated, with refrigerated items discarded after 48 hours. These observations indicate a failure to adhere to the facility's food safety policies, potentially affecting all residents consuming food from the kitchen.
Deficiencies in Personal Care and ADLs for Residents
Penalty
Summary
The facility failed to provide adequate personal care for three residents, resulting in deficiencies in activities of daily living (ADLs). Resident R129, who has a diagnosis of Parkinsonism and requires assistance with ADLs, reported not receiving a shower for four weeks and had unwashed hair with white flakes. Despite being scheduled for showers twice a week, records showed R129 only received bed baths and one refusal. The resident's fingernails were also observed to be long and dirty. Staff cited a shortage of slings for mechanical lifts as a reason for not providing showers, although the resident did not refuse the care. Resident R61, diagnosed with hemiplegia and requiring assistance with ADLs, was observed with long chin hairs and reported not being shaved during bed baths. The resident expressed a preference for bed baths but did not prefer having long facial hair. The care plan indicated a need for substantial assistance with personal hygiene, which was not adequately provided. Resident R79, with diagnoses including Osteomyelitis and Chronic Obstructive Pulmonary Disease, reported excessively long toenails and could not recall seeing a podiatrist since admission. The Director of Nursing acknowledged the need for toenail trimming and stated that non-diabetic residents should have their toenails monitored and trimmed during ADL care. The facility's policy on ADLs and nail care emphasized regular grooming, which was not adhered to in these cases.
Failure to Document and Date PICC Line Dressings
Penalty
Summary
The facility failed to ensure proper documentation and care for PICC line dressings for two residents. For one resident, a rolled gauze dressing was observed on multiple occasions without a visible date or transparent dressing, and the insertion site was not visible. The LPN reported that the gauze dressing was used because the resident had previously pulled out the PICC line, and acknowledged that a transparent dressing should have been in place. The Unit Manager confirmed the absence of a date and transparent dressing. The resident's records showed no documentation of PICC line dressing changes, despite the administration of IV antibiotics being recorded. For the second resident, a transparent PICC line dressing was observed without a date. The Unit Manager confirmed the dressing should have been dated and noted that the resident's records lacked documentation of PICC line assessments or dressing changes since admission. An order for weekly dressing changes was entered by the infection control nurse on the day of observation. The Director of Nursing confirmed that PICC line dressings should be transparent, changed weekly, and dated, with assessments conducted when hanging each IV. The facility's policy outlined the procedure for dressing changes, which was not followed in these cases.
Deficiencies in Mechanical Lift Use and Smoking Policy Enforcement
Penalty
Summary
The facility failed to ensure the proper use and maintenance of a mechanical lift sling, leading to a fall and subsequent hospitalization of a resident. The resident, who had a history of cerebral infarction with left hemiplegia, muscle weakness, and anxiety disorder, fell from a mechanical lift due to a ripped sling. The incident occurred during a transfer from the bed to a lounger-chair, with only one CNA and a housekeeper present, contrary to the facility's policy requiring two trained staff members. The CNA did not inspect the sling before use, and the sling was found to be frayed and torn near the strap. Additionally, the facility failed to secure smoking and vape pens for residents, as observed with a resident who had a vape pen attached to a necklace and used it in their room, against the facility's smoking policy. The resident admitted to using the vape pen in their room due to delays in being assisted to the designated smoking area. The facility's policy prohibits smoking inside the building and requires smoking materials to be stored at the nursing station unless deemed safe by Resident Services. The facility's policies on safe lifting and smoking were not adhered to, resulting in unsafe conditions for residents. The mechanical lift policy mandates two staff members for transfers and regular equipment checks, while the smoking policy requires smoking materials to be kept at the nursing station and prohibits indoor smoking. These lapses in policy enforcement contributed to the deficiencies noted in the report.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications securely and in accordance with professional principles for four residents. One resident was found with a white pill in a medication cup on their overbed table, and they were unsure how long it had been there. Another resident had an orange gel capsule in a medication cup on their window sill, which they did not take because they had a bowel movement and informed the nurse of their refusal. A third resident had a red inhaler on their overbed table and was unsure if it was supposed to be kept in their room. A fourth resident was found with a small plastic bag containing over 20 pills, which they stated they were not taking and did not need. This resident had a medical history of major depressive disorder, dementia with mood disturbance, and adjustment disorder with mixed anxiety and depressed mood. The Director of Nursing was shown the bag of pills and confirmed the facility's policy that medications should be taken with the nurse present, and any refused medications should be removed from the room. The facility's policy on medication storage emphasizes proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Failure to Repair Malfunctioning Bed
Penalty
Summary
The facility failed to repair or replace a malfunctioning bed for a resident, identified as R136, who had been readmitted following a right above-knee amputation. The resident reported that the height adjustment of their bed had not worked since their admission, and despite informing multiple staff members, including maintenance and nursing staff, the issue was never addressed. During an observation, the resident demonstrated that while the head and foot adjustments worked, the height adjustment did not, producing a loud grinding noise instead. Interviews with facility staff, including a CNA and an LPN, revealed that they were aware of the bed's malfunction but had not reported it to maintenance. The Maintenance Director stated that they were unaware of the issue and that no work orders had been submitted regarding the bed. The Director of Nursing indicated that the expectation was for nursing staff to report such issues directly to maintenance or complete a work order. However, the facility administrator could not identify a policy addressing the reporting of malfunctioning equipment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,079 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Warren | 0.4 mi | ★★★★★ | 22 | 0 |
| Windemere Park Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Harmony Village Of Warren | 2 mi | ★★★★★ | 1 | 0 |
| The Villa At City Center | 2 mi | ★★★★★ | 7 | 0 |
| Father Murray, A Villa Center | 2.2 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.